General practitioners' experiences of providing somatic care for patients with severe mental illness: a qualitative study.

BACKGROUND: Patients dealing with severe mental illnesses (SMI) often face suboptimal clinical outcomes and higher mortality rates due to a range of factors, including undetected physical health conditions. The provision of care for individuals with SMI is frequently disjointed, as they engage with diverse healthcare providers. Despite this fragmentation, primary care, particularly general practitioners (GPs), assumes a pivotal role in the care of SMI patients. Our study aimed to delve into the first-hand experiences of GPs in delivering somatic care to SMI patients, concentrating on the challenges they encounter and the strategies they employ to navigate these difficulties. METHODS: We conducted in-depth interviews with fifteen GPs, utilizing a semi-structured interview guide, supplemented by ethnographic observations during clinical consultations in general practice. Through inductive coding, interview transcripts and observational field notes were systematically analysed using interpretative phenomenological analysis (IPA). The findings were then deliberated upon within the author group. RESULTS: GPs revealed that managing the chronic somatic care of SMI patients posed significant challenges. These challenges encompassed the multifaceted needs of patients, their behavior tied to symptoms, a lack of care continuity, and overarching time constraints. To tackle these challenges, the GPs had devised various strategies. However, all participants underscored the critical importance of having adequate time to properly prepare for, conduct, and follow up on consultations. CONCLUSION: The GPs' interactions with SMI patients brought numerous challenges, although treating these patients were concurrently acknowledged as vital and fulfilling. The findings suggest that increased allocated time in general practice consultations for patients with SMI is important to support the somatic treatment requirements of this patient group.

Implementing PCR testing in general practice-a qualitative study using normalization process theory.

BACKGROUND: The COVID-19 pandemic brought attention to a need for rapid testing of large populations. Experiences from community-based testing settings show that there can be workload difficulties, logistical challenges and socioeconomic downsides to large scale Polymerase Chain Reaction (PCR) testing. Alternative testing arenas have therefore been considered. Rapid point-of-care (POC) PCR test methods have since been developed and could have potential to surveille viral respiratory infections. It is, however, unknown if PCR testing can be successfully implemented routinely in general practice. The aim of this study was to assess factors that enable and inhibit the implementation of point-of-care PCR testing for acute respiratory tract infection in general practice. METHODS: Fourteen general practices in the east Zealand area in Denmark were included in the study and given access to POC PCR testing equipment during a flu season. The participating clinics were initially trained in the use of a POC PCR testing device and then spent 6 weeks testing it. We conducted qualitative interviews with general practitioners (GPs) and their staff, before and after the testing period, specifically focusing on their clinical decision-making and internal collaboration in relation to POC PCR testing. We used normalization process theory to design the interview guides and to analyze the data. RESULTS: Professionals reported no clinical need for a POC PCR testing device in a non-pandemic clinical setting. Results were delivered faster, but this was only timesaving for the patient and not the GP, who had to perform more tasks. CONCLUSION: In its current form, the added diagnostic value of using POC PCR testing in general practice was not sufficient for the professionals to justify the increased work connected to the usage of the diagnostic procedure in daily practice. TRIAL REGISTRATION: n/a.

Challenges in reaching patients with severe mental illness for trials in general practice-a convergent mixed methods study based on the SOFIA pilot trial.

BACKGROUND: Patients with severe mental illness (SMI) die prematurely due to undetected and inadequate treatment of somatic illnesses. The SOFIA pilot study was initiated to mend this gap in health inequity. However, reaching patients with SMI for intervention research has previously proven difficult. This study aimed to investigate the recruitment of patients with SMI for the SOFIA pilot study in 2021. METHODS: We used a mixed-method convergent design. The qualitative material comprised 20 interviews with general practitioners (GPs) and staff, during patient recruitment. The quantitative data consisted of process data on baseline characteristics, GPs reported reasons for excluding a patient, reported reasons for patients declining participation, and registered data from a Danish population of patients with SMI. We used thematic analysis in the qualitative analysis and descriptive statistics for the quantitative analysis. Pillar integration was used for integrating the material. RESULTS: Our findings show that selection bias occurred in the pilot study. We describe four main themes based on the integrated analysis that highlights selection issues: (1) poor data quality and inconsistency in defining severity definitions troubled identification and verification, (2) protecting the patient and maintaining practice efficiency, (3) being familiar with the patient was important for a successful recruitment, and (4) in hindsight, the GPs questioned whether the target population was reached. CONCLUSIONS: In the light of theories of professions and street-level bureaucracy, we find that the main drivers of the patient selection bias occurring in the SOFIA pilot study were that 1) GPs and staff mended eligibility criteria to protect certain patients and/or to minimize workload and maintain efficiency in the practice 2) the data from the GP record systems and the digital assessment tool to assist recruitment was not optimal. Interventions targeting this patient group should carefully consider the recruitment strategy with a particular focus on professionals' discretionary practices and information technology pitfalls. TRIAL REGISTRATION: The pilot trial protocol was registered on the 5th of November 2020. The registration number is NCT04618250 .

Introducing quality clusters in general practice - a qualitative study of the experiences of cluster coordinators.

BACKGROUND: In 2018, the concept of clusters was introduced as a new model for data-driven quality improvement in general practice in Denmark. However, there is little research on the development and implementation of general practice clusters. The study explores how the cluster coordinators responsible for leading the clusters forward enacted and experienced their role during the early years of the clusters with attention to the challenges and enablers perceived in the process. METHODS: Qualitative, semi-structured interviews with 25 cluster coordinators from clusters that had carried out at least two meetings on a specific professional topic. The coordinators represented clusters of varying sizes and different geographic locations. Key topics in the interview guide were the development and structure of the cluster, the role of the coordinator, obtainment of data for the meetings, the role of external support, the form and content of the meetings, the participation and engagement of the members. A thematic analysis - shaped by the original aims and categories of the study while also being open to emerging themes - was performed on the transcribed interview material. RESULTS: Important enablers in the process of developing the clusters included the positive engagement of the GPs, the support offered by regional quality units and a national quality organisation for general practice, and the funding provided by the formal cluster framework. Challenges initially included setting up the clusters administratively and translating the open cluster concept into a local, workable model; and later obtaining relevant data for the cluster meetings and facilitating peer discussions about the data. CONCLUSION: The coordinators generally experienced that the development of the clusters had progressed relatively fast with engagement from most of the participating GPs. Still, challenges with data obtainment, data analysis, and facilitation will have to be addressed ongoingly. Future research should investigate learning processes at the cluster meetings and how the clusters impact clinical practice and collaborative relations between general practice and other health care providers.

Implementing an intervention to reduce use of antibiotics for suspected urinary tract infection in nursing homes - a qualitative study of barriers and enablers based on Normalization Process Theory.

BACKGROUND: Overuse of antibiotics in the elderly population is contributing to the global health problem of antibiotic resistance. Hence, it is important to improve prescribing practices in care facilities for elderly residents. In nursing homes, urinary tract infection (UTI) is the most common reason for antibiotic prescription but inappropriate prescriptions are frequent. In order to reduce the use of antibiotics for suspected urinary tract infection in this context, a complex intervention based on education as well as tools for reflection and communication had been developed and trialed in a group of nursing homes. The presents study explored the barriers and enablers in implementing this complex intervention. METHODS: After the intervention trial period, a qualitative interview study was performed in six of the nursing homes that had received the intervention. The study included 12 informants: One senior manager, four nurses, six healthcare assistants, and one healthcare helper. Normalization Process Theory was used to structure the interviews as well as the analysis. RESULTS: The intervention was well received among the informants in terms of its purpose and content. The initial educational session had altered the informants' perceptions of UTI and of the need for adopting a different approach to suspected UTIs. Also, the study participants generally experienced that the intervention had positively impacted their practice. The most important barrier was that some of the interventions' clinical content was difficult to understand for the staff. This contributed to some problems with engaging all relevant staff in the intervention and with using the observation tool correctly in practice. Here, nurses played a key role in the implementation process by regularly explaining and discussing the intervention with other staff. CONCLUSION: The results suggest that it is possible to implement more evidence-based practices concerning antibiotics use in nursing homes by employing a combination of educational activities and supportive tools directed at nursing home staff.

Quality clusters in general practice: associations between cluster organization and general practitioners' self-reported benefits.

BACKGROUND: Quality clusters were introduced as a quality improvement concept in Danish general practice in 2018. This new concept anchored quality improvement in local clusters managed by general practitioners (GPs). OBJECTIVES: To describe the cluster organization and GPs' self-reported benefits of participating in them and explore the associations between cluster organization and self-reported benefits. METHODS: A national survey in Danish general practice gathering information about cluster organization (cluster size, cluster meetings, participants, and content) and GPs' self-reported benefits (overall benefit, internal changes in the clinic, and improved external collaboration). RESULTS: One hundred and eight (95%) clusters and 1,219 GPs (36%) were included. Cluster size varied from 10 to 68 GPs (34 GPs on average). Approximately 70% of GPs reported moderate to very high overall benefit from cluster participation. Most GPs experienced changes in their clinic organization (68%), drug prescriptions (78%), and patient care (77%). Collaboration was reported improved between the GPs (86%), municipality (50%), and hospital (36.2%). GPs in clusters with 3-6 planned meetings per year (odds ratio [OR] 1.9; confidence interval [CI] 1.3-2.9), mixed meeting types (OR 1.7; CI 1.2-2.4), group work (OR 1.7; CI 1.1-2.5), and use of guidelines in their meetings (OR 1.8; CI 1.3-2.4) had statistically significantly higher odds for reporting overall benefit of participating in clusters compared with GPs in clusters without these characteristics. CONCLUSIONS: Frequent and active meetings with a relevant meeting content are positively related to GPs' perceived benefits and with improved collaboration between GPs in the clusters. There seems to be a potential for developing collaboration with other healthcare providers.

The survey visit as a key evaluative event in accreditation-a qualitative study of survey visit experiences among surveyors and general practice professionals.

BACKGROUND: Accreditation is a widely employed quality assurance concept in health care and the survey visit is the central method for assessing participating organisations' compliance with accreditation standards. Despite this, research on the survey visit as a method for assessing compliance is scarce. In Denmark a mandatory accreditation programme was introduced for general practice clinics in 2016. We performed a qualitative, explorative study of the reflections and actions of surveyors and general practice professionals (GPs and staff) concerning the production of information about compliance with the accreditation standards in relation to the survey visit. METHODS: We conducted qualitative interviews with GPs and staff from general practices in two Danish regions before and after their survey visit. We also interviewed the surveyors. We observed survey visits to qualify the interviews and analysis. All interviews were audio recorded, transcribed, and analysed using an integrative approach. RESULTS: The surveyors combined documents, questioning of the professionals, and visual impressions of the clinic to assess compliance. They sought to de-dramatise the survey visit and to generate a natural conversation with attention to workflows. Trust in the professionals' statements was fundamental to the surveyors' approach, and they were confident in their ability to assess compliance. Their level of scrutiny was influenced by their observations and the quality of documents. The general practice professionals had generally sought to comply with the standards and to give an authentic portrait of the clinic. The few cases of misrepresention concerned standards that the professionals found too excessive. CONCLUSION: The validity of the survey visit as a method to assess compliance was highly dependent on the professionals' willingness to convey a realistic picture of their practice. Since they were generally willing to do so, the trust-based approach seemed suitable for identifying cases of non-compliance caused by insufficient understanding of the standards. However, it can be difficult for the surveyors to detect when the professionals engage in misrepresentation due to disagreements with the standards. Thus, when adopting a trust-based approach to the survey visit, it seems particularly important to ensure that the professionals view the standards as meaningful and manageable.

"My private theory is that it's all in the head": Understandings of chronic widespread pain among social workers from municipality job centers in Denmark.

People with chronic widespread pain (CWP) are often unfit for work, and consequently they are dependent on the municipality job center to receive social support and sickness benefits. The job center's case management is based on a social worker's assessment of the citizen's health condition. This qualitative study investigates social workers' understandings of CWP. Interviews were carried out with 12 social workers. The results showed that the participants predominantly experienced the citizens' illnesses as psychosocially mediated-referring to trauma, or a lack of meaning in the citizens' lives. Only a few participants mentioned possibilities for somatic explanations of CWP.

Reducing Antibiotic Prescriptions for Urinary Tract Infection in Nursing Homes Using a Complex Tailored Intervention Targeting Nursing Home Staff: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: Urinary tract infection (UTI) is the most common reason for antibiotic prescription in nursing homes. Overprescription causes antibiotic-related harms in those who are treated and others residing within the nursing home. The diagnostic process in nursing homes is complicated with both challenging issues related to the elderly population and the nursing home setting. A physician rarely visits a nursing home for suspected UTI. Consequently, the knowledge of UTI and communication skills of staff influence the diagnosis. OBJECTIVE: The objective of this study is to describe a cluster randomized controlled trial with a tailored complex intervention for improving the knowledge of UTI and communication skills of nursing home staff in order to decrease the number of antibiotic prescriptions for UTI in nursing home residents, without changing hospitalization and mortality. METHODS: The study describes an open-label cluster randomized controlled trial with two parallel groups and a 1:1 allocation ratio. Twenty-two eligible nursing homes are sampled from the Capital Region of Denmark, corresponding to 1274 nursing home residents. The intervention group receives a dialogue tool, and all nursing home staff attend a workshop on UTI. The main outcomes of the study are the antibiotic prescription rate for UTI, all-cause hospitalization, all-cause mortality, and suspected UTI during the trial period. RESULTS: The trial ended in April 2019. Data have been collected and are being analyzed. We expect the results of the trial to be published in a peer-reviewed journal in the fall of 2020. CONCLUSIONS: The greatest strengths of this study are the randomized design, tailored development of the intervention, and access to medical records. The potential limitations are the hierarchy in the prescription process, Hawthorne effect, and biased access to data on signs and symptoms through a UTI diary. The results of this trial could offer a strategy to overcome some of the challenges of increased antibiotic resistance and could have implications in terms of how to handle cases of suspected UTI. TRIAL REGISTRATION: ClinicalTrials.gov NCT03715062; https://clinicaltrials.gov/ct2/show/NCT03715062. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17710.

Experiences of accreditation impact in general practice - a qualitative study among general practitioners and their staff.

BACKGROUND: Accreditation is a widespread tool for quality management in health care. However, there is lack of research on the impact of accreditation, particularly in general practice. This study explores how general practitioners and their staff experienced the impact of a mandatory accreditation program in Denmark. METHODS: Qualitative interviews with general practitioners and staff from 11 clinics. The respondents were interviewed twice: during preparation and after the survey visit. The interviews were analyzed using thematic analysis, and all specific changes and other types of impact were extracted from the transcribed interview data from each clinic. RESULTS: The impact of accreditation varied markedly among the clinics as did the participants' overall assessments of accreditation. Concerning specific changes in behavior and physical infrastructure, some clinics had only implemented a few minor changes in response to accreditation, some had made a relatively moderate number of changes, and a few clinics had made relatively many changes including a few pronounced ones. Further, some participants experienced that accreditation had enhanced knowledge sharing or upgraded competencies, and increased job satisfaction. However, the workload related to accreditation was emphasized as a problem by a majority of the professionals and for a few, accreditation had influenced job satisfaction negatively. CONCLUSION: Accreditation may affect general practice clinics in very different ways. In spite of several examples of positive impact, the results suggest that it is difficult to design a mandatory accreditation program for general practice in which most professionals experience that the benefits of accreditation equal the resources used in the process.

Inter-Sectoral Collaboration in Municipal Health Centres: A Multi-Site Qualitative Study of Supporting Organizational Elements and Individual Drivers.

INTRODUCTION: Community health centres accommodating different professional groups are expected to improve inter-sectoral collaboration between primary care providers. This study aimed to identify what has been done to support inter-sectoral collaboration between municipal professionals and general practitioners in health centres, and to explore the interactions that emerge between these professionals at the operational level. METHODS: The study was a multi-site qualitative study carried out in four municipal health centres in a Danish region. The study was based on documents and qualitative interviews with general practitioners, and municipal professionals and administrators in each of the health centres. A content analysis was conducted. RESULTS: The study found that little attention had been given to the organizational prerequisites for enhanced inter-sectoral collaboration in the health centres. Even though some health centres had employed coordinators, these did not play a significant role as facilitators of collaboration partly due to a lack of political and managerial attention. At the operational level, inter-sectoral collaboration was limited to ad hoc interactions between professionals. Although these interactions could be useful, they did not evolve into more systematic forms of collaboration. CONCLUSION: The gap between policy visions and actual implementation efforts found in this study suggests that a more active and focused engagement from the political-administrative level is needed if the visions of increased inter-sectoral collaboration in health centres are to be realised.

Between three chairs: Experiences of being a patient with chronic widespread pain in an intersectoral setting in Denmark.

This study explores how patients with chronic widespread pain experience their contacts with health and social services in Denmark, including general practice, hospitals, and municipality job centers. We analyzed interviews with 10 patients using interpretative phenomenological analysis and found the following four superordinate themes: meeting different attitudes, fragmentation of treatment, the importance of time, and feeling trapped. Findings show that when patients do not feel understood by professionals, they can resort to withdrawal strategies. On an organizational level, patients said that they needed sufficient time in meetings and better coordination of interventions in and between the health and social care sectors.

Understanding accreditation standards in general practice - a qualitative study.

BACKGROUND: Accreditation is a widely adopted tool for quality control and quality improvement in health care, which has increasingly been employed for general practice. However, there is lack of knowledge of how accreditation is received and experienced by health professionals in general practice. This study explores how general practitioners (GPs) and their staff experienced the comprehensibility of accreditation standards and how they worked to increase their understanding of the standards. The study was conducted in Denmark where accreditation was mandatory in general practice from 2016 to 2018. METHODS: The study consists of qualitative interviews with general practitioners and staff from 11 general practices that were strategically sampled among practices set to receive their survey visit in 2017. Participants were interviewed twice; once during the preparation phase and once after the survey visit. GPs and staff were interviewed separately. The interviews were analysed inductively using thematic analysis. RESULTS: Understanding the requirements of the accreditation standards was a major challenge for the professionals when preparing for the accreditation survey visit. The participants attempted to increase their understanding of the standards in several ways including the use of regional support options and seeking out experts and colleagues. However, participants had mixed experiences with the various support options and many found the sense making work frustrating and time consuming. CONCLUSION: The results point to the importance of considering the level of specificity in accreditation standards and how to ensure an organisational set-up that can offer appropriate support to primary care clinics in terms of understanding what is required to meet the standards.

Influences of peer facilitation in general practice - a qualitative study.

BACKGROUND: Practice facilitation is increasingly used to support guideline implementation and practice development in primary care and there is a need to explore how this implementation approach works in real-life settings. We focus on a facilitation intervention from the perspective of the visited practices to gain a more detailed understanding of how peer facilitation influenced practices and how they valued the facilitation. METHODS: The facilitation intervention was conducted in general practice in the Capital Region of Denmark with the purpose of supporting the implementation of chronic disease management programmes. We carried out a qualitative study, where we observed 30 facilitation visits in 13 practice settings and interviewed the visited practices after their first and last visits. We then performed a thematic analysis. RESULTS: Most of the respondents reported that facilitation visits had increased their knowledge and skills as well as their motivation and confidence to change. These positive influences were ascribed to a) the facilitation approach b) the credibility and know-how associated with the facilitators' being peers c) the recurring visits providing protected time and invoking a sense of commitment. Despite these positive influences, both the facilitation and the change process were impeded by several challenges, e.g. competing priorities, heavy workload, problems with information technology and in some cases inadequate facilitation. CONCLUSION: Practice facilitation is a multifaceted, interactive approach that may affect participants in several ways. It is important to attune the expectations of all the involved actors through elaborate discussions of needs, capabilities, wishes, and approaches, and to adapt facilitation interventions according to an analysis of influential contextual conditions and change opportunities.

Exploring drivers and challenges in implementation of health promotion in community mental health services: a qualitative multi-site case study using Normalization Process Theory.

BACKGROUND: There is an increased interest in improving the physical health of people with mental illness. Little is known about implementing health promotion interventions in adult mental health organisations where many users also have physical health problems. The literature suggests that contextual factors are important for implementation in community settings. This study focused on the change process and analysed the implementation of a structural health promotion intervention in community mental health organisations in different contexts in Denmark. METHODS: The study was based on a qualitative multiple-case design and included two municipal and two regional provider organisations. Data were various written sources and 13 semi-structured interviews with 22 key managers and frontline staff. The analysis was organised around the four main constructs of Normalization Process Theory: Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. RESULTS: Coherence: Most respondents found the intervention to be meaningful in that the intervention fitted well into existing goals, practices and treatment approaches. Cognitive Participation: Management engagement varied across providers and low engagement impeded implementation. Engaging all staff was a general problem although some of the initial resistance was apparently overcome. Collective Action: Daily enactment depended on staff being attentive and flexible enough to manage the complex needs and varying capacities of users. Reflexive Monitoring: During implementation, staff evaluations of the progress and impact of the intervention were mostly informal and ad hoc and staff used these to make on-going adjustments to activities. Overall, characteristics of context common to all providers (work force and user groups) seemed to be more important for implementation than differences in the external political-administrative context. CONCLUSIONS: In terms of research, future studies should adopt a more bottom-up, grounded description of context and pay closer attention to the interplay between different dimensions of implementation. In terms of practice, future interventions need to better facilitate the translation of the initial sense of general meaning into daily practice by active local management support that occurs throughout the implementation process and that systematically connects the intervention to existing practices.

Role enactment of facilitation in primary care - a qualitative study.

BACKGROUND: Facilitation is a widely used implementation method in quality improvement. Reviews reveal a variety of understandings of facilitation and facilitator roles. Research suggests that facilitation interventions should be flexible and tailored to the needs and circumstances of the receiving organisations. The complexity of the facilitation field and diversity of potential facilitator roles fosters a need to investigate in detail how facilitation is enacted. Hence, the purpose of this study was to explore the enactment of external peer facilitation in general practice in order to create a stronger basis for discussing and refining facilitation as an implementation method. METHODS: The facilitation intervention under study was conducted in general practice in the Capital Region of Denmark in order to support an overall strategy for implementing chronic disease management programmes. We observed 30 facilitation visits in 13 practice settings and had interviews and focus groups with facilitators. We applied an explorative approach in data collection and analysis, and conducted an inductive thematic analysis. RESULTS: The facilitators mainly enacted four facilitator roles: teacher, super user, peer and process manager. Thus, apart from trying to keep the process structured and focused the facilitators were engaged in didactic presentations and hands-on learning as they tried to pass on factual information and experienced based knowledge as well as their own enthusiasm towards implementing practice changes. While occasional challenges were observed with enacting these roles, more importantly we found that a coaching based role which was also envisioned in the intervention design was only sparsely enacted meaning that the facilitators did not enable substantial internal group discussions during their facilitation visits. CONCLUSION: Facilitation is a complex phenomenon both conceptually and in practice. This study complements existing research by showing how facilitation can be enacted in various ways and by suggesting that some facilitator roles are more likely to be enacted than others, depending on the context and intervention design and the professional background of the facilitators. This complexity requires caution when comparing and evaluating facilitation studies and highlights a need for precision and clarity about goals, roles, and competences when designing, conducting, and reporting facilitation interventions.

Accreditation in general practice in Denmark: study protocol for a cluster-randomized controlled trial.

BACKGROUND: Accreditation is used increasingly in health systems worldwide. However, there is a lack of evidence on the effects of accreditation, particularly in general practice. In 2016 a mandatory accreditation scheme was initiated in Denmark, and during a 3-year period all practices, as default, should undergo accreditation according to the Danish Healthcare Quality Program. The aim of this study is primarily to evaluate the effects of a mandatory accreditation scheme. METHODS/DESIGN: The study is conducted as a cluster-randomized controlled trial among 1252 practices (clusters) with 2211 general practitioners in Denmark. Practices allocated to accreditation in 2016 serve as the intervention group, and practices allocated to accreditation in 2018 serve as controls. The selected outcomes should meet the following criteria: (1) a high degree of clinical relevance; (2) the possibility to assess changes due to accreditation; (3) availability of data from registers with no self-reporting data. The primary outcome is the number of prescribed drugs in patients older than 65 years. Secondary outcomes are changes in outcomes related to other perspectives of safe medication, good clinical practice and mortality. All outcomes relate to quality indicators included in the Danish Healthcare Quality Program, which is based on general principles for accreditation. DISCUSSION: The consequences of accreditation and standard-setting processes are generally under-researched, particularly in general practice. This is the largest study in general practice with a randomized implementation approach to evaluate the clinical effects of a nation-wide mandatory accreditation scheme in general practice. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02762240 . Registered on 24 May 2016.

The uses and implications of standards in general practice consultations.

Quality standards play an increasingly important role in primary care through their inscription in various technologies for improving professional practice. While 'hard' biomedical standards have been the most common and debated, current quality development initiatives increasingly seek to include standards for the 'softer' aspects of care. This article explores the consequences of both kinds of quality standards for chronic care consultations. The article presents findings from an explorative qualitative field study in Danish general practice where a standardized technology for quality development has been introduced. Data from semi-structured interviews and observations among 17 general practitioners were analysed using an iterative analytical approach, which served to identify important variations in the uses and impacts of the technology. The most pronounced impact of the technology was observed among general practitioners who strictly adhered to the procedural standards on the interactional aspects of care. Thus, when allowed to function as an overall frame for consultations, those standards supported adherence to general recommendations regarding which elements to be included in chronic disease consultations. However, at the same time, adherence to those standards was observed to narrow the focus of doctor-patient dialogues and to divert general practitioners' attention from patients' personal concerns. Similar consequences of quality standards have previously been framed as manifestations of an inherent conflict between principles of patient-centredness and formal biomedical quality standards. However, this study suggests that standards on the 'softer' aspects of care may just as well interfere with a clinical approach relying on situated and attentive interactions with patients.

Enablers and barriers to implementing collaborative care for anxiety and depression: a systematic qualitative review.

BACKGROUND: Collaborative care is an increasingly popular approach for improving quality of care for people with mental health problems through an intensified and structured collaboration between primary care providers and health professionals with specialized psychiatric expertise. Trials have shown significant positive effects for patients suffering from depression, but since collaborative care is a complex intervention, it is important to understand the factors which affect its implementation. We present a qualitative systematic review of the enablers and barriers to implementing collaborative care for patients with anxiety and depression. METHODS: We developed a comprehensive search strategy in cooperation with a research librarian and performed a search in five databases (EMBASE, PubMed, PsycINFO, ProQuest, and CINAHL). All authors independently screened titles and abstracts and reviewed full-text articles. Studies were included if they were published in English and based on the original qualitative data on the implementation of a collaborative care intervention targeted at depression or anxiety in an adult patient population in a high-income country. Our subsequent analysis employed the normalization process theory (NPT). RESULTS: We included 17 studies in our review of which 11 were conducted in the USA, five in the UK, and one in Canada. We identified several barriers and enablers within the four major analytical dimensions of NPT. Securing buy-in among primary care providers was found to be critical but sometimes difficult. Enablers included physician champions, reimbursement for extra work, and feedback on the effectiveness of collaborative care. The social and professional skills of the care managers seemed critical for integrating collaborative care in the primary health care clinic. Day-to-day implementation was also found to be facilitated by the care managers being located in the clinic since this supports regular face-to-face interactions between physicians and care managers. CONCLUSIONS: The following areas require special attention when planning collaborative care interventions: effective educational programs, especially for care managers; issues of reimbursement in relation to primary care providers; good systems for communication and monitoring; and promoting face-to-face interaction between care managers and physicians, preferably through co-location. There is a need for well-sampled, in-depth qualitative studies on the implementation of collaborative care in settings outside the USA and the UK.

Almost half of the Danish general practitioners have negative a priori attitudes towards a mandatory accreditation programme.

INTRODUCTION: The objective of this study was to analyse Danish general practitioners' (GPs) a priori attitudes and expectations towards a nationwide mandatory accreditation programme. METHODS: This study is based on a nationwide electronic survey comprising all Danish GPs (n = 3,403). RESULTS: A total of 1,906 (56%) GPs completed the questionnaire. In all, 861 (45%) had a negative attitude towards accreditation, whereas 429 (21%) were very positive or posi-tive. The negative attitudes towards accreditation were associated with being older, male and with working in a singlehanded practice. A regional difference was observed as well. GPs with negative expectations were more likely to agree that accreditation was a tool meant for external control (odds ratio (OR) = 1.87 (95% confidence interval (CI): 1.18-2.95)), less likely to agree that accreditation was a tool for quality improvement (OR = 0.018 (95% CI: 0.013-0.025)), more likely to agree that it would affect job satisfaction negatively (OR = 21.88 (95% CI: 16.10-29.72)), and they were generally less satisfied with their present job situation (OR = 2.51 (95% CI: 1.85-3.41)). CONCLUSION: Almost half of the GPs had negative attitudes towards accreditation. FUNDING: The three Research Units for General Practice in Odense, Aarhus and Copenhagen initiated and funded this study. TRIAL REGISTRATION: The survey was recommended by the Danish Multipractice Committee (MPU 02-2015) and evaluated by the Danish Data Agency (2015-41-3684).